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1.
Z. T. Awad T. J. Dickason C. J. Filipi Y. Shiino R. E. Marsh T. Tomonaga M. R. Tasset S. Mittal 《Surgical endoscopy》1999,13(6):626-627
As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate
method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence
of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic
surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient.
We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the
gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased
costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With
experience, modifications were made, resulting in the technique described herein.
Received: 15 September 1998/Accepted: 15 January 1999 相似文献
2.
Complications of laparoscopic antireflux surgery in childhood 总被引:6,自引:2,他引:4
Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux
disease (GERD) in children.
Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux
disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between
5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique.
Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications
in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior
vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery
was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal
perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through
a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric
emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication
was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy.
Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of
complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach.
Received: 16 November 1999/Accepted: 16 December 1999/Online publication: 5 June 2000 相似文献
3.
Background: Inappropriate length of the myotomy incision along the stomach, the most common technical fault during Heller's cardiomyotomy,
is related to the difficulty of identifying the gastro-esophageal junction, in particular during laparoscopic surgery. The
goal of this study was to evaluate the contribution of endoscopy to gastro-esophageal junction identification during laparoscopic
Heller's cardiomyotomy.
Methods: In a group of 19 patients with intraoperative endoscopy with laparoscopic Heller's cardiomyotomy, surgical and endoscopic
criteria for gastro-esophageal junction identification have been assessed. Then postoperative results of this group were compared
with those of another group of 16 patients previously operated on without intraoperative endoscopy.
Results: Endoscopic and laparoscopic criteria for gastro-esophageal junction identification were discordant in 11 patients (11/19,
58%). The cardia was in all these cases at a more distal site with endoscopic criteria. Complications ascribable to suboptimal
technique were more frequent in the group without intraoperative endoscopy (7/16 patients) than in the other group (2/19 patients).
Conclusions: Endoscopy during laparoscopic Heller's cardiomyotomy is of great assistance in identifying the cardia, and thereby could
improve surgical outcomes.
Received: 20 October 1998/Accepted: 20 January 1999 相似文献
4.
The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia 总被引:4,自引:2,他引:2
Mittal SK Awad ZT Tasset M Filipi CJ Dickason TJ Shinno Y Marsh RE Tomonaga TJ Lerner C 《Surgical endoscopy》2000,14(5):464-468
Background: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free
antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing.
Methods: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment.
Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position
with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length
two standard deviations below the mean for height was considered abnormally short.
Results: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic
crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening
procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal
junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity
of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive
value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's
esophagus was the most sensitive test for predicting the need for a lengthening procedure.
Conclusions: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with
other parameters are needed.
Received: 1 April 1999/Accepted: 10 August 1999/Online publication: 17 May 2000 相似文献
5.
During the course of a laparoscopic Heller myotomy, a patient thought to have primary achalasia was found instead to have
an adenocarcinoma of the gastroesophageal junction. Aspects of this patient's clinical course, which are exemplary of malignant
pseudoachalasia, are discussed, as are ways in which this not uncommon error in diagnosis can be avoided.
Received: 6 August 1997/Accepted: 26 November 1997 相似文献
6.
Background: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication
for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural
fibers when encircling the lower esophagus.
Methods: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall
intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric
approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the
esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult.
Results: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis
(Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal
sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was
no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital
stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months.
Conclusion: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication
to be both simple and effective.
Received: 29 March 1996/Accepted: 28 May 1996 相似文献
7.
Background: We report our initial experience using operative esophageal manometry as an adjunct to endoscopy to determine the completeness
of esophagogastric high-pressure zone (HPZ) obliteration during laparoscopic Heller myotomy.
Methods: Between July 1997 and October 1998, we performed laparoscopic Heller myotomies in 20 patients (eight male, 12 female; median
age, 41 years). Mean duration of symptoms was 3.2 ± 2.6 years (r= 0.5–11), and 45% of the patients had received prior dilation or toxin injection. A 16-channel esophageal manometry catheter
was placed prior to anesthesia, with sites crossing the lower esophageal sphincter (LES). An endoscope was passed intraoperatively
to localize the squamocolumnar junction, and the myotomy was performed. While the translucency was imaged in the area of the
incision, we determined the adequacy of myotomy by visual assessment of LES and gastric cardia opening in response to endoscopic
air insufflation. Manometry was then performed to detect any potential residual high pressure at the myotomized esophagogastric
junction (EGJ). If it was found, the locus of persistent pressure was identified by probing along the myotomy, and residual
muscle fibers were cut to yield a minimum pressure at the EGJ.
Results: A persistent HPZ was identified after the initial myotomy in 10 of 20 patients (50%). A Dor fundoplasty completed the operation.
The mean operating time was 2.6 ± 0.5 h (median, 2.5; r= 2–3.5 h), and the mean hospital stay was 1.6 ± 1 days (median, 1, r= 1–5 days). The mean LES pressure was 2 ± 3 mmHg immediately postmyotomy (p < 0.001 compared with preoperative value). Of 20 patients, only two have reported recurrence of dysphagia (10%). One had
a recurrent HPZ on manometry, and one developed esophagitis, which resolved with omeprazole.
Conclusions: Our initial experience suggests that operative esophageal manometry is a useful adjunct to upper endoscopy during laparoscopic
Heller myotomy, quantitatively assuring obliteration of the nonrelaxing LES and HPZ.
Received: 1 March 1999/Accepted: 30 June 1999 相似文献
8.
Background: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically
with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort
to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting.
Methods: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included
postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were
compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures.
Results: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically
significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required
in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing
from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly
lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length
of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set
by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases.
Conclusions: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications,
operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be
successfully transferred from academic medical centers to the community hospital setting.
Received: 7 October 1996/Accepted: 14 May 1997 相似文献
9.
Laparoscopic management of colorectal endometriosis 总被引:5,自引:2,他引:3
Background: In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery.
The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center.
Methods: From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively
evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate,
length of hospitalization, and complications.
Results: In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal
involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas.
Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases
required conversion due to the overall severity of the pelvic disease. For those who did (n= 12) and did not (n= 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90–390) and 110 min (range,
45–355), respectively; the median length of hospitalization was 4 days (range, 3–7) and 1 day (range, 0–4), respectively.
A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1–32), 28 patients
were improved, and 24 of these had near or total resolution of preoperative symptoms.
Conclusions: Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic
treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients.
Received: 1 April 1998/Accepted: 22 March 1999 相似文献
10.
Background: This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia
who have persistent or recurrent dysphagia following balloon dilatation.
Methods: Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior
cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet
fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation,
and heartburn (0 = none–3 = maximal) and esophageal manometry.
Results: Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis
was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result,
three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative
complications. Median (IQR) postoperative stay was 3 (2–4) days. At 3-month reassessment, there was a reduction in the median
dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient
had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure
was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery.
Conclusions: Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of
a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have
had previous balloon dilatation with complication and success rates similar to published results in patients who have not
undergone previous dilatation.
Received: 7 January 1998/Accepted: 22 June 1998 相似文献
11.
Awad ZT Filipi CJ Mittal SK Roth TA Marsh RE Shiino Y Tomonaga T 《Surgical endoscopy》2000,14(5):508-512
Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians
have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this
report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with
primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus.
Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair
(n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months
(range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive
techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms,
and a shortened hospital stay.
Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000 相似文献
12.
Background: Between February 1995 and June 1998, 30 laparoscopic Duhamel pull-through procedures were performed in our department.
Methods: Our main aim was to prove the feasibility of the laparoscopic abdominal Duhamel procedure for different localizations of
Hirschsprung disease. We used one camera port and three working ports. The sigmoid colon and posterior rectum were mobilized
laparoscopically. A standard posterior colo-anal anastomosis was fashioned and a stapler was used for the anterior anastomosis.
The top of the rectum was then closed by endo stapler under laparoscopic vision.
Results: Thirty patients underwent laparoscopic surgery for this procedure. Three laparoscopic procedures were converted because of
technical difficulties. The operative time was 100–330 mn. Oral feeding was started at a mean postoperative time of 2.5 days.
Mean postoperative hospitalization was 9 days. Early postoperative complications included 1 anastomotic leak, 1 retrorectal
abscess, 2 urinary infections, and 1 evisceration (after conversion). No enterocolitis or enterocolitis-like symptoms were
noted. All patients now have daily spontaneous bowel movements.
Conclusion: The laparoscopic Duhamel procedure can be performed safely, giving good results.
Received: 6 November 1998/Accepted: 12 February 1999 相似文献
13.
Iatrogenic thoracic migration of the stomach complicating laparoscopic Nissen fundoplication 总被引:1,自引:0,他引:1
Background: Intrathoracic gastric herniation after laparoscopic Nissen fundoplication is an uncommon but potentially life-threatening
complication that may present in the early or late postoperative period.
Methods: A retrospective analysis was performed on all patients undergoing antireflux surgery from December 1991 to June 1999.
Results: Nine cases of gastric herniation occurred after 511 operations (0.17%). Patients presented with the condition 4 days to 29
months after surgery. Eight of these nine patients (89%) had reported vomiting in the immediate postoperative period. Seven
patients (78%) reported persistent odynophagia. A factor common to all patients was that posterior crural repair had not been
performed.
Conclusions: Measures should be undertaken to prevent postoperative vomiting after laparoscopic Nissen fundoplication. Posterior crural
repair is essential after surgery in all cases.
Received: 12 July 1999/Accepted: 22 November 1999/Online publication: 8 May 2000 相似文献
14.
Background: We evaluated the use of the ultrasonically activated (harmonic) scalpel (HS) in the performance of laparoscopic cholecystectomy
(LC).
Methods: A total of 282 consecutive patients, 64 of whom had acute cholecystitis at the time of surgery, underwent LC using HS dissection.
Indications for surgery included chronic pain (180 cases), episodes of acute cholecystitis (89 cases), pancreatitis (five
cases), and jaundice (seven cases). Twenty-seven patients had preoperative endoscopic retrograde cholangiopancreatography
(ERCP).
Results: The mean operating time was 29 ± 9 mins. Eleven procedures were converted to open surgery, (four due to bleeding, six due
to unclear anatomy, and one due to an inflammatory mass caused by gangrene/perforation). Complications occurred in 14 patients.
They included minor port site infection (four cases), pulmonary atelectasis (three cases), urinary retention (two cases),
intraoperative cathetherization not routinely performed, bile leak (two cases, both from cystic duct; one of the cystic duct
leaks occurred because of dislodgement of the occluding clip, the other may have been due to duct injury from the clip), pulmonary
embolus (one case), and myocardial infarction (one case). Neither of the latter complications were fatal. One patient required
a postoperative transfusion due to a fall in hematocrit of 3.2 gr/dl.
Conclusions: LC performed with the HS is feasible and effective. Operating time and blood loss were minimal, and the conversion rate was
low (3.9%). There were no bile duct injuries. Use of the HS makes dissection easier, thereby helping to reduce operative time
and lower the need for conversion to open surgery.
Received: 30 April 1999/Accepted: 22 November 1999/Online publication: 4 August 2000 相似文献
15.
Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children 总被引:2,自引:0,他引:2
Infants and children requiring fundoplication for gastroesophageal reflux frequently have significant associated medical
problems necessitating placement of a gastrostomy at the time of fundoplication. This article reviews the techniques, complications,
and results of 141 laparoscopic Stamm gastrostomies performed in conjunction with laparoscopic fundoplication in infants and
children. The three techniques employed were the T-fastener technique (63/141) which is best utilized in patients with thick abdominal walls; the trocar-site technique (53/141) which is technically easy to perform but prone to infection and fistula formation; and the U-stitch technique (26/141). General complications of laparoscopic gastrostomy include development of gastrocutaneous fistulae (2/141), perigastrostomy
cellulitis (8/141), and the formation of granulation tissue at the gastrostomy site (45/141). The only perioperative death
was due to a technical error during gastrostomy tube placement. Our preferred method for laparoscopic gastrostomy in most
children is the U-stitch technique.
Received: 19 March 1996/Accepted: 8 May 1996 相似文献
16.
Oberg S Peters JH DeMeester TR Lord RV Johansson J Crookes PF Bremner CG 《Surgical endoscopy》1999,13(12):1184-1188
Background: It has been suggested that endoscopic grading of the gastroesophageal flap valve is a good predictor of the reflux status.
Methods: To test this hypothesis, 268 symptomatic patients underwent endoscopic grading of the gastroesophageal valve using Hill's
classification, with grades I through IV. Esophageal acid exposure, lower esophageal sphincter characteristics, and the degree
of esophageal mucosal injury were compared among the groups.
Results: The prevalence of a mechanically defective sphincter, abnormal esophageal acid exposure, erosive esophagitis, and Barrett's
esophagus increased with increasing alteration of the gastroesophageal valve. The presence of a grade IV valve indicated increased
esophageal acid exposure in 75% of patients. As a predictor, this is similar to lower esophageal sphincter pressure but not
as good as the presence of esophageal mucosal injury.
Conclusions: Endoscopic grading of the gastroesophageal valve provides useful information about the reflux status but is less useful as
an indicator of gastroesophageal reflux disease (GERD) than the presence of esophageal mucosal injury.
Received: 28 April 1999/Accepted: 23 June 1999 相似文献
17.
Laparoscopic management of acute cholecystitis 总被引:2,自引:1,他引:1
A. Bickel A. Rappaport V. Kanievski I. Vaksman M. Haj N. Geron A. Eitan 《Surgical endoscopy》1996,10(11):1045-1049
Background: Laparoscopic cholecystectomy for acute cholecystitis is considered feasible and safe, but it is associated with a higher
rate of conversion to laparotomy than elective cholecystectomy because of technical reasons and anatomical changes related
to the inflammatory process. The value of several factors that might influence its successful completion has not been studied
completely yet, including the role of residents in operating such cases under attending-surgeon surveillance.
Methods: In a retrospective nonrandomized study, the medical charts of 182 patients that were operated for acute cholecystitis (94
of whom via the laparoscopic approach) were studied. The study was also conducted to study the effect of residents as operators.
Results: Male sex, duration of right upper abdominal pain, and the severity of the inflammatory process have all been significantly
and independently correlated with increased conversion rate to laparotomy. Operation time was not longer than that of the
open approach, and hospital stay and complication rate were lower. Operations performed by residents were associated with
twofold conversion rate to laparotomy, without increased complication rate (p < 0.012).
Conclusions: Laparoscopic management of acute cholecystitis is feasible and safe. Considering the factors discussed above, lowering the
threshold for conversion is necessary in selected cases to maintain low morbidity rate. Integrating laparoscopic cholecystectomy
for acute cholecystitis into surgical residency should be studied.
Received 5 January 1996/Accepted 22 April 1996 相似文献
18.
Minimally invasive surgery for posterior gastric stromal tumors 总被引:9,自引:3,他引:6
Background: Because involvement is extremely rare, surgery for gastric stromal tumors consists of local excision with clear resection
margins. The aim of this study was to report the results of a consecutive series of nine patients with posterior gastric stromal
tumors that were excised using a minimally invasive method.
Methods: Patients received a general anesthetic before placement of three laparoscopic ports— a 10-mm (umbilical) port for the telescope
and two working ports, a 12-mm port (left upper quadrant) and a 10-mm port (right upper quadrant). Grasping forceps were placed
through an anteriorly placed gastrotomy to deliver the tumor through the gastrotomy into the abdominal cavity, thus allowing
an endoscopic linear cutter to excise the tumor with a cuff of normal gastric tissue.
Results: Nine consecutive patients with a median age of 73 years (range, 47–83) were treated. In seven patients, laparoscopic removal
of the tumor was achieved. Two patients required conversion to an open operation because the tumor could not be delivered
into the abdominal cavity. The median length of postoperative stay for the seven patients in whom the procedure was completed
laparoscopically was 3 days (range, 2–6).
Conclusions: Posterior gastric stromal tumors can be removed safely using this minimally invasive method. Delivery of the tumor through
the gastrotomy is essential for success.
Received: 30 April 1999/Accepted: 12 July 1999 相似文献
19.
Cost-effectiveness of different diagnostic strategies in patients with nonresectable upper gastrointestinal tract malignancies 总被引:1,自引:0,他引:1
Mortensen MB Ainsworth AP Langkilde LK Scheel-Hincke JD Pless T Hovendal C 《Surgical endoscopy》2000,14(3):278-281
Background and methods: Using a simple model, this retrospective study evaluated the cost-effectiveness of different diagnostic strategies used for
pretherapeutic detection of patients with disseminated or locally nonresectable upper gastrointestinal tract malignancies
(UGIM). Of 162 consecutive UGIM patients referred for treatment, 73 (45%) had disseminated or locally nonresectable disease,
and these patients were eligible for evaluation.
Results: The noninvasive diagnostic strategies (computed tomography [CT] with ultrasonography [US] and endoscopic ultrasonography
[EUS]) had a low procedure cost, but a diagnostic strategy based on CT with US or CT with US and laparoscopy was not cost-effective.
The inclusion of endoscopic or laparoscopic ultrasonography seemed necessary to the provision of a cost-effective strategy
because both techniques had a high diagnostic accuracy combined with a low cost. A change in diagnostic strategy from CT with
US to CT with US and EUS resulted in a net saving regarding the cost of each additional nonresectable patient detected, but
this strategy still required up to 20% futile explorative laparotomies.
Conclusions: The combination of endoscopic and laparoscopic ultrasonography was cost-effective and had no complications in this study.
We use this strategy as our standard in the pretherapeutic evaluation of UGIM patients.
Received: 27 November 1998/Accepted: 12 July 1999 相似文献
20.
360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease 总被引:1,自引:0,他引:1
Basso N De Leo A Genco A Rosato P Rea S Spaziani E Primavera A 《Surgical endoscopy》2000,14(2):164-169
Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure
has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However,
a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication
has recently been reported.
Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic
360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months.
Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first
and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the
hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to
the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform
an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus
and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses).
Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD.
At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications
related to the use of the mesh.
Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients
undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed.
Received: 9 July 1998/Accepted: 19 April 1999 相似文献